Football and mental health: Defying the game's 'hypermasculine' culture of silence

David Wheeler's frustration is tangible.

The midfielder has also been witness to what he calls a culture of 'hypermasculinity' - "outdated perceptions of what it is to be a man" - preventing players from "admitting vulnerability".

It's a situation that Wheeler, now at League One Wycombe, feels the game needs to address quickly. With 2020 figures revealing a 50% rise in the number of players seeking counselling support from the Professional Footballers' Association (PFA) between 2018 and 2019, his concerns seem well-founded.

As he puts it: "We're leaving open the possibility of a fire raging in someone's head."

But Wheeler's unease is also informed by his personal journey.

He has gone from seeking psychological support for panic attacks to leading a unique research project he hopes will help change what one manager describes as football's "Dark Ages" attitude to mental health.

Dealing with nerves might be part of any player's pre-match preparation, but while many will be familiar with a tingling of 'butterflies' during the warm-up, fewer have to cope with bouts of vomiting. It's a routine Wheeler lived with for a long time.

"When I was growing up I had extreme levels of competitive anxiety," he says.

"There were times when I'd be sick in the toilet before going out for kick-off or at half-time, or I couldn't eat properly, which obviously affected my performance.

"Because I didn't address it well, it ended up seeping into my personal life. On holiday, shopping or sitting in a restaurant, I'd start having panic attacks out of the blue. That's when I started seeking help."

Fortunately, thanks to a concerted effort to understand and manage the anxiety that affected the early part of his career, those days are behind him. As Wheeler says: "I'm able to feel those feelings of intense anxiety, but it doesn't overwhelm me anymore."

That effort led him towards an undergraduate degree and to his recently completed post-graduate research, overseen by former England women's football team psychologist Dr Misia Gervis. She describes its findings as "unique" because she believes Wheeler's status as a current player offers a "true reflection" of how psychology is seen within the game.

Wheeler met Gervis during his time at Queens Park Rangers and has also worked with her at Wycombe.

As the first sport psychologist appointed by the English Football Association to support any of its national teams, she accompanied the Lionesses to the 2007 World Cup and 2009 European Championship. She too believes a hypermasculine culture discourages players from asking for mental health support.

She recalls how on one occasion a manager prevented her from working with a player she says was vulnerable and actively seeking help.

"It's easier to show butch manliness because then you create a barrier no one's looking behind," she says.

"But what I see is fragility and vulnerability that is never spoken about, never owned and hidden away because there's no safe space for it to be expressed, and that is really problematic."

Wheeler's study includes testimony from 10 elite managers who have worked with national teams, Premier League or EFL clubs. He spoke with them about football's apparent reluctance to fully embrace psychological support.

One manager described a "lack of honesty in football" that sees "players struggling because they don't want to be seen as struggling", adding: "You've still got the archaic mentality that it's weakness."

It's something Wheeler encountered himself during a career that started at Lewes in 2007 and has included stints at Staines Town, Exeter City, Portsmouth, MK Dons and QPR in addition to his current spell with Wycombe. He paints a vivid picture of how a macho dressing room atmosphere can affect mentality.

"I've experienced something pretty close to the best you could find, I'd imagine, in the Football League, and I've also experienced something pretty toxic as well and the difference is quite stark," he says.

"There were times where it's been so bad that I dreaded going in every day. It wasn't a positive place to be and I just didn't want to be there.

"On multiple occasions in my career I've watched as players almost sleepwalk themselves into a pretty dangerous situation where they're not fit to play a match, but they end up playing because they don't want to give up their spot in the team.

"It's like a cauldron of pressure at times, especially when the manager might be under pressure. I think the lack of a sports psychologist presence feeds into the stigma and taboo of it [psychological support].

"If you celebrated it and you had [a psychologist] as a permanent fixture, it would be like the manager almost saying: 'We've got someone on our team, so if you're having any issues go to them and be open about it. It won't get back to me if you don't want it to and it's not going to affect me selecting you.'

"By not having someone, it's almost saying either we don't value the players' mental health highly, or you're saying: 'I'd rather not know about it, so if you need it, go and find it elsewhere.' I think both are concerning, in different ways."

Wheeler's research recommends mandating Premier League and Championship clubs to employ an accredited, full-time psychologist. He notes that the cost of doing so - a 2018 study estimated between £27,000 and £100,000 a year, depending on experience - shouldn't be prohibitive for teams in either division.

But he also believes that clubs can take other steps - such as encouraging players to step outside of the football 'bubble'.

"I think [change] comes from celebrating individuality and promoting people to explore their personality and develop their character, over and above just being a footballer," he says.

"A lot of the scenarios I've witnessed where people get into a spiral of anxiety, depression, gambling or eating disorders often stem from having a very narrow idea of who you are.

"That narrow idea is defined as a footballer, first and foremost, and sometimes solely. So, once that's not going well, then that's everything."

Across last season, PFA members at clubs in the Premier League, EFL and the Women's Super League were invited to complete a confidential survey on mental health. Some 22% reported experiencing severe anxiety over the previous month.

Yet while the scale of the mental health challenge facing the game is evident, the responsibility on clubs to provide psychological support - and their willingness to do so - is less clear.

English clubs with leading 'Category One' academies are required to employ a full-time psychologist registered (or gaining the accreditation required to register) with the Health and Care Professions Council, the body responsible for regulating health and care professions in the UK.

However, there is no stipulation for Premier League or EFL teams to hire an accredited performance psychologist to help senior players - the rules set out in the Elite Player Performance Plan only apply to academies.

Many elite clubs do employ psychologists to work with first-team players - including at least half of the Premier League - but respected figures within the game believe more can be done.

In an interview with The Football Psychology Show in 2021, Wycombe assistant manager Richard Dobson, who established at the club a psychology programme described as the "biggest in Europe" by the FA's former psychology lead, said that the system allows clubs to "play at psychology".

"What I'm seeing now is a lot of people recently qualified from university going into jobs at club academies to tick boxes, because the Elite Player Performance Plan says you have to have a psychologist," he explained.

"So, they [the clubs] go: 'Well, we've brought one in - although we are paying them peanuts - but we've got one, so we are doing psychology now.' But they're not. It's not as simple as that. You have to understand psychology at a far deeper level."

Wheeler is among a growing band of current and former players to draw attention to football's provision of psychological support. In a BBC Sport interview conducted in August, Real Madrid assistant coach Davide Ancelotti suggested that all elite players would soon be employing their own psychologists.

Wheeler agrees with the need for more mental health support, but he is also conscious of the potential for abusing the system.

"Even players who can afford top psychologists can quite easily be sucked in by someone who's just very good at marketing themselves on YouTube, which even happens at Premier League clubs," he says.

"They get in people who've written a book or have a good social media following but don't actually have the qualifications or expertise to do what they're saying that they can do in a safe way."

While there has been progress in highlighting the positive impact psychological support can have, with Tyrone Mings, Jordan Pickford and Jack Harrison among a number of Premier League players speaking openly about their work with psychologists, Wheeler believes a quicker pace of change is needed.

"I think the tide is definitely turning, it's just frustratingly slow," he says.

"One of the managers in my study said: 'We're still in the Dark Ages, how many more young men are we going to fail before we get our act together?'

"That is my worry and it's why I'm impatient about changing things, because I can't help but be aware of how many people are going to suffer in the meantime."